Connecting the Dots

In 2002, I published a book on patient examination procedures that included information on the procedural coding of the recommended examinations. The book should have been published in 2000, but I had trouble finding a publisher. Why? Because some publishers who sent the book to "experts" for review felt part of the book was blasphemous.

After two years, I finally found a publisher who accepted the book. I did this by approaching a publisher who was not strictly academically oriented. The part of the book some felt was blasphemous actually made perfect sense to the publisher.

By now, you are surely wondering, "What was considered blasphemous?" Simply put: combining how to perform an examination with how to code an examination. I had mixed academic clinical information with practice management information. Traditionally, these topics had not been mixed; they had always been compartmentalized into clinical care and practice management, and treated as two unrelated subjects.

Mixing coding and clinical aspects of patient examinations has long been thought detrimental. Many think practice management aspects of coding the examination cheapen or degrade the clinical intentions, and financial factors should not be considered in learning proper patient care. This would only be correct if mixing of the two areas resulted in the practice management concerns becoming the sole consideration for an examination process.

Examination coding consists of more than financial factors. The primary purpose of the codes is to serve as guidelines for examination content, levels of case complexity and interprofessional communications. Practice management and financial considerations are secondary. Of course, while the practice management and financial aspects of coding are secondary, they are necessary and play a vital role – but one that is synergistic, not detrimental.

In my practice, I use the review of systems requirements in the history portion of new- and established-patient examinations to show how clinical and coding requirements can overlap synergistically, as they were intended.

Systems Review

A review of systems is required for four of five new-patient and three of five established-patient examinations. (Table 1)¹ Lower-level new- and established-patient examination codes for problem-focused examinations and below (99201, 99211 and 99212) do not require a review of systems. This is attributed to the use of these codes for examinations of localized, uncomplicated problems.

Codes for expanded problem-focused (99202 and 99213) and detailed levels (99203 and 99214) require problem-focused and extended reviews of systems, respectively. These codes are used for examinations of problems with increased complexity.

The problem-focused review is for system(s) related to the problems identified by the history of the present illness. For example, if the patient's lower back pain is thought to be purely musculoskeletal in origin, the musculoskeletal system as a whole would be reviewed. Another example is a patient with lower back and leg pain that are thought to be a radicular problem. The musculoskeletal and nervous systems would be reviewed.

The extended review of systems moves beyond the systems related to the history of the present illness, "extending" into other systems. These systems might refer pain to the patient's area(s) of complaint. Obviously a case is more complex if other systems and referral pain patterns must be considered; the degree of differential diagnosis required increases.

Codes for the comprehensive examination levels require that all systems be reviewed: systems related to the history of the present illness, systems that could refer symptoms to the areas of the present illness, and the remaining of the 14 reviewable systems. (Table 2)

Note that the two highest levels for new-patient examinations are both "comprehensive" and require review of all systems. The differentiation between the two levels lies in the degree to which each system is reviewed – essentially, the number of questions asked regarding each system. This differentiation also applies to other history components and examination content.

The levels of history and system reviews are related to the patient's need, which unfolds as the history and examination proceed. This is a clinical guideline and relates to the patient's health. The only relationship the levels of history and review have to practice management is that the varying levels of patient need result in varying levels of examinations, which have varying levels of fees.

Code / System Selection

The appropriate code is selected after the evaluation process is complete. The code itself communicates the extent of the patient's needs, and the clinical documentation must reflect that the degree of work required for the code was performed by the doctor. Fees are assigned last. All codes have relative values that help establish their fee levels. Obviously, as the patient's degree of need increases, the degree of evaluation and the fee increase.

This information must be cross-referenced with additional clinical information. Once you have established the systems to be reviewed (Table 3), you must establish the way to review them.

The systems will be selected by patient need; however, the majority of reviews will be of the musculoskeletal and nervous systems. This is logical since the majority of patients enter chiropractic offices with complaints related to these systems.

The selection of additional systems is a little less obvious. There has to be an additional thought process. The systems and diseases that refer pain to the spine are a good place to start.

One of my personal preferences is to review the systems that refer symptoms, but that produce cancers known to spread to the spine and other skeletal structures. (I selected cancer because of its severity and common occurrence.) According to Yochum, the types of cancers that most commonly metastasize to the skeleton are from the breast, lung, prostate, kidney, thyroid and bowel.² This group represents the female genitourinary system, the male genitourinary system, the respiratory system, the endocrine system and the gastrointestinal system.

My most common review questions are about the signs, symptoms and cancers associated with the above systems. The most common signs and symptoms for two of these systems appear in Table 4 as examples.³

Beyond this point, when all systems must be reviewed, the remaining systems in the list of 14 are reviewed using the same principles – i.e., signs and symptoms of the most common conditions and cancers.

With the above information based on only a single component of examination coding, it should be obvious why combining how to perform an examination with how to code an examination is logical. Ninety percent of what was discussed here is clinical in nature. The codes were not established solely to communicate a procedure and its fee. They have greater structure, as can be seen in this example using only a fraction of the history component of examination codes.

Mixing of clinical and practice management topics is still frowned upon. Hopefully, I will make a few converts with this and future writings.

References

1. E & M Coding Made Easy, 4th Edition. Los Angeles, CA: Professional Management Information Corporation, 2006.
2. Yochum T, Rowe L. Essentials of Skeletal Radiology, 3rd Edition.; Baltimore, MD: Lippincott, Williams and Wilkins, 2005.
3. Swartz, Mark. Textbook of Physical Diagnosis, History and Examination. Philadelphia, PA: W. B. Saunders Company, 1989.